CHAPTER 15
Hepatobiliary
Test Taking Tip
• Familiarity with the distinction between benign liver tumors is critical. Know the diagnostic modalities necessary to identify hepatic adenomas, focal nodular hyperplasia (FNH), hemangiomas, as well as infectious etiologies such as pyogenic, amebic, or hydatid cysts.
ANATOMY
List the ligaments of the liver:
The falciform ligament, coronary ligaments, and the right and left triangular ligaments.
What structures are contained within the hepatoduodenal ligament?
Porta hepatis: proper hepatic artery, portal vein, common bile duct (CBD)
What line divides the liver into left and right lobes?
Cantlie line (runs from the middle of the gallbladder fossa anteriorly to the inferior vena cava posteriorly)
How many Couinaud segments are in the liver?
8
Which segments are removed in a right hepatectomy?
Segments 5 to 8
Which segments are removed in a right trisegmentectomy?
Segments 4 to 8
Which segments removed are in a left hepatectomy?
Segments 2 to 4
Which segments are removed in a left lateral trisegmentectomy?
Segments 2 and 3
Which segments are removed in a left trisegmentectomy?
Segments 2, 3, 4, 5, 8
How much percentage of blood flow does the portal vein supply to the liver?
70%
What percentage of cardiac output accounts for hepatic blood flow?
25%
How much of the liver’s oxygen supply is provided by the hepatic artery?
50%
FIGURE 15-1. Couinaud’s liver segments (I through VIII) numbered in a clockwise manner. The left lobe includes segments II to IV, the right lobe includes segments V to VIII, and the caudate lobe is segment I. (Reproduced from Brunicardi FC, Andersen DK, Billiar TR, et al. Schwartz’s Principles of Surgery. 9th ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.)
FIGURE 15-2. Hepatic resection nomenclature and anatomy. Hepatic segments removed in the formal major hepatic resections are indicated. The International Hepato-Pancreato-Biliary Association (IHPBA) Brisbane 2000 terminology also is presented. IVC, inferior vena cava; LHV, left hepatic vein; MHV, middle hepatic vein; RHV, right hepatic vein. (Reproduced from Brunicardi FC, Andersen DK, Billiar TR, et al. Schwartz’s Principles of Surgery. 9th ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.)
How much does the portal vein contribute to total hepatic blood flow?
Two-thirds
How many hepatic veins are there?
Three (right, middle, and left)
What is the approximate length of the CBD?
Approximately 7 cm
What is normal CBD diameter?
0.5 to 1.5 cm
What is the arterial supply of the bile ducts?
Primarily the right hepatic artery
Where does the sympathetic innervation of the gallbladder originate?
Celiac axis
What is the parasympathetic innervation of gallbladder?
Vagus nerve
What are ducts of Luschka?
Accessory ducts directly from the liver bed into the gallbladder
PHYSIOLOGY
How much bilirubin is produced daily in normal adults?
About 250 to 350 mg
How much bilirubin is produced from turnover of senescent red blood cells?
Approximately 85%
What is the most common cause of hyperbilirubinemia in adults?
Cholelithiasis
What is the major metabolite of heme?
Bilirubin
What is the name of sinusoidal macrophages?
Kupffer cells
What is the half-life of albumin?
20 days
What is the half-life of transferrin?
6 days
Which major protein is produced by the liver?
Albumin
What are bile acids conjugated with to form bile salts?
Glycine and taurine
What is the major site of bile acid reabsorption?
Distal ileum
What autosomal recessive disorder causes an increase in conjugated bilirubin without elevation of liver function tests (LFTs)?
Dubin-Johnson syndrome
What percentage of the population has gallstones?
Approximately 10%
What group of Indians in southern Arizona are at high risk for gallstones?
Pima Indians
What population is at lowest risk for developing gallstones?
Sub-saharan Africans
How are gallstones classified?
Cholesterol, black pigment, or brown-pigment stones
What is the main composition of black pigmented stones?
Calcium bilirubinate
What is the main composition of brown pigmented stones?
Calcium salts of unconjugated bilirubin
What causes gallstone formation?
Cholesterol supersaturation, accelerated crystal nucleation, and gallbladder hypomotility
What are the 2 primary bile acids?
Cholate and chenodeoxycholate
What is the most common inherited cause of hyperbilirubinemia?
Gilbert syndrome (decreased activity of the enzyme glucuronyl transferase)
Which enzyme found in the cells of the bile duct rises with bile duct obstruction?
Alkaline phosphatase
The liver is the site of synthesis of all of the coagulation factors except:
von Willebrand factor
What is type I Crigler–Najjar syndrome?
Severe unconjugated hyperbilirubinemia, kernicterus, bilirubin deposits in the brain causing severe motor dysfunction and retardation.
What is type II Crigler–Najjar syndrome?
Less severe form, enzyme activity is 10% of normal
Which substance is metabolized by gut bacteria to lactic acid that converts ammonia to ammonium salt?
Lactulose
List the secondary bile salts:
Lithocholate, deoxycholate, and ursodeoxycholate
What hormone is a potent stimulator of gallbladder contraction?
Cholecystokinin
BENIGN BILIARY DISEASE
Is prophylactic cholecystectomy recommended in diabetics?
No
What is the incidence of endoscopic retrograde cholangiopancreatography (ERCP)-induced pancreatitis?
About 5%
Which is a rapid, noninvasive imaging study that provides detailed biliary tree and pancreatic duct images equal to those of ERCP?
Magnetic resonance cholangiopancreatography (MRCP)
What percentage of pigmented stones and cholesterol stones are seen on plain abdominal films?
50% and 20%, respectively
What is the principal imaging modality for the diagnosis of cholelithiasis?
Ultrasonography
What is the sensitivity of ultrasonography for stones greater than 2 mm?
>95%
What is the probability of complications requiring surgery in a patient with a history of biliary colic?
1% to 2% per year
What is the surgical management of uncomplicated biliary colic and documented gallstones?
Elective laparoscopic cholecystectomy
What percentage of patients with acute cholecystitis have positive enteric bacteria culture from the bile?
50%
What is hydrops of the gallbladder?
Chronic cystic duct obstruction and gallbladder distention with clear mucoid fluid.
What is Mirrizzi syndrome?
Impacted stone in the gallbladder neck causing extrinsic compression of the common (hepatic) duct
What is porcelain gallbladder?
Calcification of the gallbladder wall; cholecystectomy is indicated to prevent carcinoma
What is Murphy sign?
Inspiratory arrest upon right upper quadrant (RUQ) palpation
What percentage of patients with gallstones have CBD stones?
15% to 20%
What is the most common cause of cholangitis?
Stone impacted in the CBD (85% of the time)
Which organisms are most commonly cultured from bile?
Escherichia coli, Klebsiella, Pseudomonas, Proteus, enterococci
What is the constellation of RUQ pain, jaundice, and fever?
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
